Strategies to increase childhood tuberculosis case detection at the primary health care level: Lessons from an active case finding study in Zambia

Abstract

Introduction In high TB burden settings, it is estimated that 10–20% of total notifications should be children, however, currently only 6–8% of the total TB notifications in Zambia are children. We assessed whether the implementation of a multicomponent strategy, at primary healthcare facilities, that systematically targets barriers at each step of the childhood TB diagnostic cascade can increase childhood TB case detection. Methods We conducted a controlled, interrupted time series analysis to compare childhood TB case notifications before (January 2018—December 2019), and during implementation (January 2020—September 2021) in two intervention and two control Level 1 hospitals in Lusaka, Zambia. At each of the intervention facilities, we implemented a multicomponent strategy constituting: (1) capacity development on childhood TB and interpretation of chest x-ray, (2) TB awareness-raising and demand creation activities, (3) setting up fast track TB services, (4) strengthening of household contact tracing, and (5) improving access to digital chest X-ray for TB screening and Xpert MTB/Rif Ultra for TB diagnosis, through strengthening sample collection in children. Findings Among 5,150 children < 15 years screened at the two intervention facilities during the study period, 503 (9.8% yield) were diagnosed with TB. Of these, 433 (86.1%) were identified through facility-based activities (10.5% yield) and 70 (13.9%) were identified through household contact tracing (6.9% yield). Overall, 446 children (88.7%) children with TB were clinically diagnosed. Following implementation of the multicomponent strategy, the proportion children contributed to total TB notifications immediately changed by +1.5% (95%CI: -3.5, 6.6) and -4.4% (95%CI: -7.5, 1.4) at the intervention and control sites, respectively (difference 6.0% [95%CI: -0.7, 12.7]), p = 0.08); the proportion of childhood notifications increased 0.9% (95%CI: -0.7, 2.5%) each quarter at the intervention sites relative to pre-implementation trends, while declining 1.2% (-95%CI: -1.8, -0.6) at the control sites (difference 2.1% [95%CI: 0.1, 4.2] per quarter between, p = 0.046); this translated into 352 additional and 85 fewer childhood TB notifications at the intervention and control sites, respectively, compared to the pre-implementation period. Conclusion A standardized package of strategies to improve childhood TB detection at primary healthcare facilities was feasible to implement and was associated with a sustained improvement in childhood TB notifications.

Knowledge, attitudes, and practices towards childhood tuberculosis among healthcare workers at two primary health facilities in Lusaka, Zambia

“…Although we didn’t find any participant characteristics that were associated with good knowledge towards childhood TB, evidence from other settings suggests that previous training is associated with increased knowledge in childhood TB [ 9 , 24 ] and duration of work experience is associated with a good attitude [ 9 ]. Additional evidence from the same setting [ 13 ] and other settings [ 25 – 27 ] indicates that capacity development of healthcare workers leads to improved childhood TB case detection. The improvement in case detection is likely driven by a prior enhancement of KAP among healthcare professionals.…”

“…We conducted a cross-sectional prospective study which was nested within an the main TB REACH Wave 7 study whose objective was to strengthen case finding in children [ 13 ].…”

Pediatric Tuberculosis: A Review of Evidence-Based Best Practices for Clinicians and Health Care Providers

“…Moreover, there has been a growing recognition of the need to prioritize and strengthen pediatric TB prevention and treatment programs to decrease morbidity and mortality in children. Routine, systematic TB screening in settings where children seek care and child-focused case-finding efforts, like household contact investigations, can prevent disease and death by facilitating the provision of TB preventive treatment (TPT) or early diagnosis and appropriate treatment of TB disease [ 14 , 16 , 20 , 23 , 24 , 25 , 26 , 27 ]. There have also been advances in the development and accessibility of pediatric formulations for both TB preventive and disease treatment regimens, which have been procured by many programs in high-burden countries [ 28 , 29 , 30 ].…”